Howship-Romberg sign

Introduction Howship-Romberg is a symptom of hernia. The Howship-Romberg sign is the earliest and most characteristic sign of the disease and the main basis for preoperative diagnosis. Especially in elderly and frail women with intestinal obstruction and Howship-Romberg sign, this disease should be considered. The obturator is insidious, the local signs are not obvious, and many patients with acute intestinal obstruction of unknown origin are admitted. Clinically, there is a tingling, numbness, and soreness in the groin area and the anterior medial thigh, and it is radiated to the inside of the knee. When coughing, stretching of the leg abduction, external rotation, due to the traction of the adductor muscle to the obturator muscle, the pain is aggravated (the obturator nerve is stressed), and vice versa is called the Howship-Romberg sign. The incidence of this sign in obturator sputum varies from 20.2% to 100%. 93.7% to 100% of patients with obturator hernia have symptoms of intestinal obstruction.

Cause

(1) Causes of the disease

Partial weakness

Closed-cell tube provides a potential channel for the occurrence of obturator, but it does not necessarily occur. Only local tissue is weak, such as rupture of the obturator muscle, displacement to the caudal side, or abnormal obturator membrane. Under the influence of it, it is possible to form defects. The hernia sac can be directly protruded through the ruptured obturator muscle, or the obturator nerve and the obturator vessel can be worn out of the obturator or the obturator vessel, and can also protrude under the obturator muscle.

2. Degeneration of pelvic floor tissue

This sputum occurs in elderly patients, mostly in the 70 to 80 years old, and Larrieu et al reported a mean age of onset of 67 years. This may be related to the degeneration of the elderly tissue leading to physiological pelvic fascia relaxation, pelvic floor muscle atrophy and so on.

3. Closed tube wide

Closed-hole sputum is more common in female patients, which is related to the fact that female obturator is wider and flatter than male. Physiologically, due to multiple pregnancies and increased intra-abdominal pressure, the female perineum can be too loose and wide.

4. Weight loss

Multiple pathologies, malnutrition, weight loss, and any wasting disease can cause the perforation of the peritoneal adipose tissue to be lost in the closed port, and the peritoneum covering the upper part of the cleft can be easily depressed to form a hernia sac.

5. Increased intra-abdominal pressure

The diseases that cause an increase in intra-abdominal pressure include chronic bronchitis, long-term cough, and habitual constipation.

(two) pathogenesis

Formation process

The formation of obturator sputum is divided into three stages: 1 epidural fat appears at the obturator. 2 There is a shallow peritoneal depression, and gradually deepens to form the hernia sac. 3 The sac is full of contents.

The sputum content of the obturator is mainly the small intestine, and it may be part of the intestinal wall (Richter's sputum) or all of the intestinal tract. The contents of the sputum may also be bladder, ovary, fallopian tube, appendix, colon, and Meckel diverticulum.

2. Way out

There are 3 ways to highlight the sacral sac: 1 The sac is passed through the obturator and is removed under the pubic muscle. 2 The sac is in the middle and upper muscle bundles of the obturator muscle, and travels along the obstructed nerve and the lower branch of the artery. 3 The sac is moved downwards and out of the closed hole and between the outer membrane. But in either case, the site is very deep, and unless the hernia sac is large, it is not easy to lick and swollen in the thigh.

3. Pathophysiology

The closed hole is a narrow fibrous duct, the surrounding tissue is tough and elastic, and the obturator nerve (waist 2~3) passes through it. When the viscera or tissue is released from the obturator, due to the crowding of the sac and the contents, the obturator nerve is inevitably pressed, and intermittent pain, soreness, numbness, and the like on the inside of the thigh and the knee joint occur. Most of the sputum contents of the obturator are small intestine, and the ankle ring is small and inelastic, so the invaded intestinal tube is prone to incarceration, and blood circulation disorder occurs in a short period of time, and intestinal narrowing and necrosis occur. Therefore, the symptoms of small bowel obstruction appear after clinical knee pain. If the contents of the sputum are partially incarcerated, there is no obvious intestinal obstruction in the early stage, and the sputum is small, and it is located deep in the pubis muscle, so that it is difficult to find.

an examination

Related inspection

Gastrointestinal CT examination of gastrointestinal imaging

Obscuration of the obturator is insidious, local signs are not obvious, and many patients with acute intestinal obstruction of unknown origin are admitted, so the preoperative diagnosis is difficult, and the misdiagnosis rate is as high as 70%. Clinicians should think of this disease, carefully analyze the medical history, combined with the clinical features of the disease and X-ray findings, can make a correct diagnosis.

1. History of medical history

(1) Older women, weight loss, patients who may have a history of similar episodes, multiple pregnancy and childbirth, and habitual constipation should be highly vigilant.

(2) In the early stage of the attack, knee pain, soreness and other signs of intestinal obstruction, but also have the characteristics of general sputum, that is, the sudden onset of intra-abdominal pressure, sudden relief after supine or rest.

2. Signs

(1) The Howship-Romberg sign is the earliest and most characteristic sign of the disease, and it is also the main basis for making a diagnosis before surgery. Especially in elderly and frail women with intestinal obstruction and Howship-Romberg sign, this disease should be considered.

(2) The inside of the fossa ovalis under the inguinal ligament can be combined with a round mass with mild tenderness. However, only some patients can find this sign.

(3) When rectal or vaginal examination, there may be a cord-like mass on the anterior wall of the pelvis, and there is tenderness; however, when the tumor is not obvious, the disease cannot be ruled out.

3. Auxiliary inspection

X-ray plain films of the abdomen and pelvis show the shadow of the inflatable bowel fixed in the upper edge of the pubic bone or the gas in the closed hole or an inflated bowel, and the blind end points to the closed hole. Closed-port hernia sac can be observed during the interstitial sac angiography, and CT can sometimes help to confirm the diagnosis.

Differential diagnosis

Inguinal pain: Many people do not care about groin pain, especially mild pain, but in fact, groin pain is a symptom of many diseases.

Femoral nerve damage: It is part of a diabetic polyneuritis lesion, sometimes accompanied by damage to other peripheral nerves. Diabetic patients may gradually have quadriceps atrophy, weak muscle strength and abnormal feeling of the thigh. It is suggested that the femoral nerve has been damaged.

Thigh tingling: Acupuncture pain in the roots of the thighs, short duration, no fixed time of attack. There are two common reasons for this condition, lumbar disc herniation and local inflammation of the thigh.

Initiation of obturator nerve compression is followed by symptoms of intestinal obstruction.

Symptom

(1) Howship-Romberg sign: When the obturator nerve is pressed close, the groin area and the anterior medial thigh appear tingling, numbness, soreness, and radiate to the inside of the knee. When coughing, stretching of the leg abduction, external rotation, due to the traction of the adductor muscle to the obturator muscle, the pain is aggravated (the obturator nerve is stressed), and vice versa is called the Howship-Romberg sign. The incidence of this sign in obturator sputum varies from 20.2% to 100%.

In the early stage of obturator or a small number of incomplete intestinal wall ticks (Richter) can be characterized by intermittent abdominal pain and pain in the thigh, knee joint muscles or soreness. Somell et al also found that in addition to obturator neuralgia, when the obturator sputum occurs, a region of hypersensitivity can be found in the area about 10 cm above the inner side of the knee.

(2) Symptoms of intestinal obstruction: 93.7% to 100% of patients with obstructive hernia have symptoms of intestinal obstruction. Because the obturator consists of bone and tough aponeurosis, the position is deep and narrow, and the ankle ring lacks elasticity. Most patients have small and inconspicuous sputum, mainly for abdominal pain, bloating, vomiting, stopping bowel movement and other intestinal obstruction. . A few manifestations of chronic incomplete intestinal obstruction.

2. Signs

(1) Howship-Romberg sign: leg extension, external rotation, groin and anterior medial thigh pain.

(2) Examination of the upper part of the femoral triangle and the fossa ovalis, about 20% of patients can reach a round mass with local tenderness.

(3) Rectal or vaginal finger examination, some patients can find the closed area of the anterior wall of the affected pelvis, there is a cord-like mass. When there is a strangulation, if the limb is abducted, the swelling of the mass is obviously aggravated.

(4) Because the sputum is small and deep, it is not easy to be detected, and the rectum is far from the closed hole. Therefore, some patients undergo a vaginal examination, and the mass is easier to find.

(5) After incarceration and strangulation of the obturator, the affected side of the lower abdomen and the suprapubic area may have obvious signs of peritonitis such as abdominal muscle tension, tenderness and rebound tenderness.

The obscuration of the obturator is insidious, the local signs are not obvious, and many patients with acute intestinal obstruction of unknown origin are admitted to the hospital. Therefore, the preoperative diagnosis is difficult, and the misdiagnosis rate is as high as 70%. Clinicians should think of this disease, carefully analyze the medical history, combined with the clinical features of the disease and X-ray findings, can make a correct diagnosis.

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